next best step? - step1inapril

[ArchivalUser]

hi, how do you answer , the next best step is q?

eg. pyloric stenosis child with electrolyte imbalance.

a. correct imbalance
b. pyloromyotomy

ans--> correct imbalance before surgery

eg. bowel perforation pt,

a. admit and give iv antibiotics
b. emergent lap

ans. emergent lap. But it also says iv antibiotics for those waiting for surgery.

What I mean is, though the answer is emergent lap, you still have to admit pt and give him abx on the way to or?

[ArchivalUser]

think of it this way:

before doing something (procedure) .. you need to make sure the patient is hemodynamically stable (unless its an emergency)

for the 1st example: pyloric stenosis is not an emergency fix .. so you must correct the electrolyte imbalance before going into surgery. The kid's been vomiting most likely so there are bound to be potassium and chloride imbalances in his system. Once that's corrected, you can proceed with the surgery and fix the issue. Its like this: if a patient with dehydration came in with confusion and altered mental status.. what would you do first? neuro consult or replenish his fluid status .. you'd give him a bolus or continuous infusion of IV fluids (0.9% NS) and then proceed with the neuro exam / consult if needed. **Always stabilize the patient first in non-emergent cases ! **

for the 2nd example: its an emergency case so what I said previously doesn't adhere. You would go straight into surgery. HOWEVER.. prior to surgery what happens? If you've done any surgery rotation ever in med school..you'll know that before any surgery whether urgent or not, they start the patient on ANCEF or UNASYN 1gm IV (30 - 60 mins prior to surgery starts) .. these are definitely necessary as pre-op antibiotics. When you cut into someone, bacteria are bound to get in no matter how sterile the environment is. ANCEF / UNASYN provide wide spectrum coverage against gram + / Gram negative ... Unasyn is most commonly used in GI / GU surgeries , while ancef (cefazolin) is chosen for most others.

hope this clears it up !

and if not, reply back with more questions

[ArchivalUser]

i misread your 2nd example:

if the answer choices include to give abx first (only) and not admit .. select that.. if however it has admit + give abx first .. no you wouldn't do that because admission takes time .. and bowel perforation is a dire emergency! .. so in that case go straight into surgery even though you would give pre-op abx first..but its not a choice so select emergent surgery.

[ArchivalUser]

you will give the AB after you put the order for immediate surgery ...meaning you making the patient ready first for OR and of course you can hang an iv AB on him while going to OR right? so ordering the surgery I think and then AB
GL

[ArchivalUser]

that was for your second option but for first one I remember we had this q in uw and it was insisted that first we have to correct any electrolyte imbalance ...then go for surgery as surgery might more compromise the electrolyte imbalance esp. in a child is more critical to be corrected plus pyloric stenosis is not that emergent ...we might consider it urgent but not emergent you will still have time to correct that right before ordering surg.
GL

[ArchivalUser]

thanks doctam3 and drelbow. helps A LOT.

it is d order in which you would give the orders in paper.

send or for emergent lap, give abx mean while. Though he will receive abx first, your priority is the laparotomy. cheers!

[ArchivalUser]

doctam you should set up your own cs course you explain things in a very clear conscise way

[ArchivalUser]

i mean step 3 course lol

[ArchivalUser]

@drelbow.. it really depends on where the question is asked.. if its a CCS case.. then yes, what you said applies in that specific order. If its a MCQ question then the obvious choice is selecting emergent surgery

[ArchivalUser]

@njcspartner.. thanks for the compliment! I do aid with CCS prep to whoever seeks it out over skype whenever I can (free of charge)